Medication for children with autism

James Scott Child & Adolescent Psychiatrist Royal Brisbane and Women’s Hospital & The University of Queensland Centre for Clinical Research

Murray

9 year old boy Autistic spectrum Escalating aggression Siblings upset and frightened Mum feeling exhausted Teachers reporting more difficulties with behaviour at school

Medications in ASD • Difficult decision • Expectations about benefits • Anxiety about risks • How do we optimise the benefits and reduce the risks of medications?

1. What can medication do for children with ASD?

Medications for ASD • Medication has virtually no role in managing the Core Features – Impaired communication – Difficulty with socialisation – Repetitive behaviours – Restricted interests

BUT

Medications can help with the emotional/ behavioural problems associated with ASD • Aggression • Inattention • Anxiety • Depression/ Mood swings • Sleep problems

Case Example Larry

Larry • 7 year old boy with ASD – Severe tantrums at home and school – Running away – Aggressive – Assessed as being very impulsive and having poor attention – Non-medication interventions hadn’t worked – Atomoxetine resulted in Larry being able to sit still and listen

2. Does this child need medication?

You need to consider • Are the problems severe enough? • Have other interventions been tried? • Will the medication help the problems?

Case study- Joseph

Joseph 13 year old boy with Aspergers Disorder – Generally happy with his own company – Interested in music – Attentive in areas of interest – Rigid, unsettled with disrupted routine – Has few friends but not concerned by this – Anger/ swearing at times – Cheeky and playful- responds to correction

Question 3 • Does the medication work?

Consider the evidence • Highest level of evidence are Meta Analyses

• Lowest level of evidence is clinical opinion • In between are case studies, open label studies and RCTs

Clinical Opinion • The opinion of clinicians regarding a particular intervention • Very low level of evidence

Open Label Studies • Baseline Measurements are taken • Intervention is provided • Post Interventions Measurements are taken • Has there been an improvement?

Open Label and Case Reports • Neuroleptics/ antipsychotics • Stimulants • Anti-depressants • Mood Stabilisers • Nor-Adrenergic Agents • Complementary Medications

Randomised Control Trials (RCTs) • Patients are randomly assigned to a

treatment group and a control group • The control group may be an active intervention or a placebo • Patients and raters should be binded • Adequate patient numbers required • Adequate time duration required

Research units on Paediatric Psychopharmacology (RUPP) • RUPP Risperidone trial – 101 patients average age 8.8 years – 49 received risperidone – 34 of risperidone children vs 6 of placebo improved at 8 weeks – Aggression, hyperactivity and Irritably decreased in responders – 23 of patients maintained their improvement at 6 months

Case Study Michael

Risperidone for ASD • Michael – 9 year old boy with autism spectrum disorder – Frequently aggressive at school – Reacting to other children in social situations – Inattention and hyperactivity treated with Ritalin- no benefit – Now suspended from school

Risperidone • Michael – Commenced on Risperidone 0.5 mg daily – Provided with support for Educational Adjustment Programme – Social difficulties persist – Behaviour and academic work markedly improved – Doesn’t show indiscriminate aggression towards other children

Methylphenidate (Ritalin) • RUPP study – Methylphenidate in ASD with ADHD – Stimulants helped some children – targeted symptoms of poor attention, hyperactivity and aggression – Other children had worsening of behaviour with more hyperactivity and impulsivity – Responses were obvious early

Case Study- Rebecca

Rebecca • 12 year old girl with autistic spectrum disorder – – – – – – – –

Unmanageable at school- excluded Violent towards parents Admitted to hospital Very unfocused Annoying, wouldn’t listen, aggression continued Ritalin prescribed Able to settle into activities Aggression resolved in hospital

A word about ADHD symptoms • Impulsive, inattentive, Hyperactive • Debilitating • Often associated with aggression • Methylphenidate (Ritain) and Atomoxetine (Strattera)

Antidepressants • Fluoxetine- (Prozac, Lovan, Zactin) – 1 RCT has shown benefits for anxiety and repetitive behaviours

• Fluvoxamine (Luvox, Faverin)

– 1 RCT suggested that there was “behavioural activation” with worsening of behaviours

• Citalopram (Cipramil)

– 1 RCT showing no benefit

Victoria

Victoria • 15 year old girl with Autism – Recent onset of Self Injurious behaviours – Aggressive to parents – Very anxious at school – Felt to be depressed – Fluoxetine – no benefit – Zoloft- no benefit – Seroquel – no benefit

Meta-Analysis • 4120 papers • 18 studies reported • Antipsychotics, n = 9 – Risperidone 6 studies up to 6 months – Aripiprazole 2 studies of 8 weeks

• SSRIs, n = 5 – only 1 RCT • Stimulants, n = 4 – Only 1 RCT (McPheeters et al 2011 Pediatrics)

4. What are the risks of medication – No benefit – May make things worse – Immediate side effects – Long term side effects – Parental anxiety and guilt – Stigma at home or at school

Risperidone • Side Effects – Average weight gain 2.7kg in 6 months – Somnolence reported in 70% of children on risperidone (9% of placebo) – Dizziness and drooling were more likely – Mild increases in heart rate and Blood pressure – Long term side effects unclear

Kate – 11 year old girl with ASD – Aggression towards mother and siblings – Family feel frustrated, angry – Wants friends but can’t keep them- because of aggression – Commenced on risperidone – Excellent response • Aggression resolved • Happier at school and home

BUT

Kate • Weight gain of 9 kg in 7 months

What can parents and carers do to make medication work?

Guidelines for medications in children

• • • • • • •

1. Try other interventions first 2. Keep a record of medication history 3. One medication change at a time 4. Don’t pressure for medication changes when times are difficult 5. Ensure the child is monitored regularly by a doctor 6. Lowest dose and lowest number of medications 7. Don’t medicate only- try other things

1. Try other interventions first • Sonya and Rod (6 years old) – Rod was stubborn, angry and aggressive – Wouldn’t listen – Work done with Sonya to follow Rod’s interests – Behaviour at home improved significantly

2. Keep a record of medication history Medication

Started Stopped Response

Ritalin 10 mg January January morning 12 12

More aggressive, couldn’t sleep

Prozac 20mg

January 12

Aggression better, less rigid

Seroquel 25mg

January 13

Less aggressive

3. One medication change at a time • Monica 9 year old girl with autism – Aggression – Doctor prescribes risperidone – Pharmacist recommends Eye-Q (Omega-3) – 1 month later aggression has settled – Which one has worked?

4. Don’t pressure for medication changes when times are difficult • Mary – 10 year old girl – Diagnosed with Aspergers Disorder since age 5 – Anxiety, aggression and oppositional behaviour created problems at home and school – Pharmacotherapy commenced but problems escalated with age – Now having home schooling with ongoing aggression

4. Don’t pressure for medication changes when times are difficult • Mary’s medication – Risperidone 2 mg twice daily – Edronax (Reboxetine) 4 mg twice daily – Endep (Amitryptilline) 50 mg at night – Valproate 200 mg twice daily

4. Don’t pressure for medication changes when times are difficult • Mary – – – – – – –

Both parents were depressed Father very reactive Both parents were mistrusting of schools Endep and Valproate ceased without worsening Father had depression treated Returned to school with school liaison3 months later- Much improved

5. Ensure the child is monitored regularly by a doctor Weight gain of 9 kg in 7 months

6. Lowest dose and lowest number of medications • Reduces side effects • Improves adherence • Safer in short and longer term

7. Don’t medicate only- try other things • Individual therapy • Family support • Evidence based Allied health support • School Liaison • Reinforce strengths • Support friendships • Dietary changes • Pharmacotherapy

Thank You